Thank you Sonya for your excellent response. I'm sorry that I'm so late posting. I started this thread last week and then got very busy with the holidays and family visiting. My original question was regarding hospital policies when using a nipple shield. Has anyone implemented a policy banning their use in the first 24 to 48 hours? Sonya, I think your policy is very sensible and I couldn't agree with you more. Thank you. I would like to use your post to develop a similar policy where I work.
I think that the majority of people posting here this past week seem to agree and see the same problems with early nipple shield use. When a nipple shield is started prior to the start of mature milk production, most of the time, the baby transfers very little colostrum and the parents and nurses are lulled into a false sense of security. It's just the same old trap we fall into of measuring the number of minutes at the breast and not milk transfer. The much better alternative is to teach the mother hand expression with spoon feeding colostrum until the baby latches, or until mature milk production starts and she can switch to pumping using hand-massage. I agree with test weighing the baby, because sometimes it does happen that the baby does okay if the shield is well-fitted, the baby is vigorous at the breast and the mother has a large supply of colostrum, but that is not the majority of cases I see. And even in those cases I worry about her ability to produce an adequate supply long-term. I agree also with what you said about the importance of skin to skin contact and hormones. I think that this probably has a much larger impact than we realize on their milk production. Even when baby is latched well on the shield, they are not touching the mother's skin on her nipple and this is most likely going to reduce her level of oxytocin. And we do know that the time in which it is most easy to increase the number of prolactin receptors in the breast is during the first 72 hours. And that is done by the long, irregular feeds of the infant at the breast during the colostral phase. So how does putting a plastic nipple of the mother's nipple at that time, impact the growth and differentiation of prolactin receptors? I see many women in the office who struggle with milk production when started on nipple shields at local hospitals, some are able to maintain a milk supply for the first few months and then their supply begins to dwindle. And I have to wonder how hormones play a role in that. I have heard other people remark on this list that there is very little research about the use of these nipple shields during the colostral phase of lactation. The time I find them to be most useful is with preterm infants transitioning back to the breast. When we use it then, the mother is also always pumping to maintain her milk supply. One day last week in the office, I saw 3 newborn babies for their first check ups, all 3 born at different local hospitals, every single mother was using a nipple shield that was started in the hospital. It's just unbelievable how prevalent this problem is here. 
It was brought up as well that we shouldn't judge people in an in-patient setting because they need to see a high volume of patients and they are under pressure to get the baby latched, both from the parents and other healthcare providers. However, I do also work in an inpatient setting. I work multiple jobs, so I'm in both inpatient and outpatient settings. So I can empathize. It's overwhelming. But the problem is that this quick fix doesn't really help in the long run. Most of the time, giving a nipple shield on the first day is little better than if we just gave the baby a pacifier to suck on and didn't put it to breast at all. The baby sucks on an artificial nipple, gets no colostrum and mom's milk supply is not stimulated. The other day I had a patient come out of the surgical recovery room 2 hours after a c-section with both a nipple shield and a Latch-Assist. The RN looked at her nipples and said they were inverted and immediately gave them. When I talked to her she admitted that she made no attempt to latch the baby without the shield. And upon examining the mother's nipples, they were merely bifurcated, but protruded well. The other problem I see with nurses and LC's giving these shields, is at least when we do it, we need to be giving informed consent about how it could impact their milk production and how to know the baby is transferring milk. I find that when questioning these parents that about 90% have not even received this basic information before they were started in the shield. The parents need to be told at a minimum, that this could result in the baby getting less milk, reducing the mother's milk supply, that she should start expressing/pumping, how to know milk is being transferred and how to know the baby is getting enough to eat. It's just malpractice not to cover this basic teaching before starting them on a shield, in my opinion. It's our job to educate people, period. If you aren't comfortable with hand expression, practice more. I found it hard at first too, but now I think it's easy to teach and I love it. I find the best success by talking the mother through it and having her watch a video. It's much easier for them if they can actually see someone else doing it. Plus it reinforces everything I'm telling her.
I don't agree with the reasoning that parents pressure us to get the baby latched. We are professionals and here to give information to the parents. If the parents chose not to take it, that's there choice. But I generally do not have many parents disagree with what I tell them, when I explain why we recommend taking the milk out of their breasts and feeding it to the baby until they latch. When I explain to them how milk production works, they understand and agree. Some, however, are very set on the idea of pumping because breast pumps are just drilled into their heads prenatally. Many women now are so obsessed with the idea that they must pump, I'm usually the first person to break the bad news to them that the pump may not get much colostrum out of their breasts. I usually show them the video from Dr. Morton about Hand Expression, and then I let them try the breast pump if they are really insistent on it. Then if they get colostrum with the pump, great. But most will then try hand expression and be amazed at how much more colostrum they get. 
Anyway, to update you on the patient I was telling you about before. She continues to pump 8 times per day, the baby is 6 weeks old now. She stopped using the shield altogether because it was 30 to 60 minutes at the shield with almost no milk transfer except during a let-down and with all the time spent pumping and bottle-feeding the mother wasn't getting any sleep. She is giving about 75% EBM by bottle and 25% formula now. She did get the MotherLove More Milk plus capsules and said her pumping production went from 16 oz per day to 18 oz per day. The baby is currently taking in about 18 oz EBM and 8 oz formula daily. She is not interested in taking Reglan because she doesn't like taking medications. She is using a symphony pump which is fitted well. She said is still pumping about 30 minutes each session. I was going to suggest reducing to 15 to 20 min, but she said that she doesn't get the majority of milk until the end of the pumping session. Her daughter started at 6# 8 oz, and is not 7# 15 oz, which puts her in the 3rd percentile. She is going back to work in a few weeks and she is wondering if she will be able to reduce the number of pumpings her day. I said that normally most people are able to reduce the length and frequency of pumpings, but in her case I'm not sure that's true. At 4 weeks I had recommended she increase feedings to baby from 16 oz to 25 oz daily, but she did not do so at first and the then from 4 to 5 weeks the baby only gained 2 oz. So I reiterated to her that the baby needs closer to 25 oz daily and then she began formula supplemenation. Then the baby gained 10 oz over the next 7 days. This is the patient who was started on a nipple shield when the baby was only 1 hour old. I do feel now looking at the baby that it is hypertonic. It's irritable and does not like going anywhere near her breast. It's quite possible that it's all due to negative experiences the baby has had with breastfeeding so far, but this baby was also SGA, postdates, induction of labor, thick meconium, etc. So there could be some other issues with the baby. I suggested the possibility of craniosacral therapy and the mother was interested in that. Other than that, I'm out of ideas. I did mention donor human milk, but she's not comfortable with that. The mother did have normal breast development during pregnancy and has no other underlying medical issues that we know of. This is such a sad and frustrating case. I also suggested she write the hospital and let them know what happened to her. I feel this may be healing for her to be able to at least vent her emotions and have something positive come from the experience, if she's able to prevent this from happening in the future. Thanks for all your help ladies.
Tricia Shamblin, RN, IBCLC




Date:    Wed, 16 Dec 2015 09:29:35 -0500
From:    Sonya Myles <[log in to unmask]>
Subject: Re: Nipple Shields

I work in a hospital setting and also in an out patient setting. I have found over the years that starting nipple shields in hospital is detrimental to breastfeeding. Babies may be latched and look as if they are nursing well, but they struggle to transfer colostrum through the shield. Mothers go home feeling they are breastfeeding, but they aren't really. The first visit to the family Dr. confirms this, excessive weight loss, mother feels like a failure and formula feeding begins. My other concern is a lack of stimulation to breasts for proper hormonal spiking. When a baby breastfeeds, hormones increase and these hormones drive long term milk supply. If there is a barrier between baby and breast, and the stimulation a breast gets is muted, like in the case of a nipple shield, then the hormones don't spike as high as they should and milk supply is affected. It's like using a cell phone in a poor reception area, your target audience (in this case, moms breasts) only hear ever third of fourth suck.

We have instituted nipple shield policies in our hospital:
1. Nipple shields can only be started by an L.C. 
2. Nipple shields can only be used after secretory activation or lactogenesis II has occurred. 
3. Mothers who use nipple shields must have a test weight done with the first use to determine if milk transfer is adequate or not. 
4. Any mother using a shield will need to pump to augment stimulation to breast tissue (frequency of pumping depends on how well baby transfers  
    milk at breast, if baby needs a top up, mom needs to pump at every feed, if mom does not need a top up, mom needs to pump at every other feed)
5. The nursing dyad must be seen within 24 to 48 hours after starting with a nipple shield to make sure everything is going well. A full feeding 
    assessment including a test weight must be done at this visit. 
6. Dyads using a nipple shield will be followed for as long as needed, for some mothers this is when they are able to wean from a shield, for other 
    mothers it is until they are super comfortable using a shield.

These rules may seem excessive, especially if you work in an area where nipple shields are used to achieve a latch. However, I have seen a baby lose 10% of their weight and a mother all of her milk supply in 24 hours with using a nipple shield. This mother was nursing well, had an excellent supply, but her baby took a few minutes to latch. Baby was 3 weeks old, and her friend suggested she use a nipple shield. Within 24 hours her excellent supply was gone and baby had lost 10% of the previous days weight. It took us 3 weeks of hard work to rescue what damage the nipple shield had done. In my opinion nipple shields should never be used lightly, and never without excellent follow up, and always with the thought that even though a latch has been achieved and it appears as if baby is nursing well, milk transfer may actually be minimal.

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